Provider Demographics
NPI:1861109001
Name:JACKSON, MADISON (MS)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 MITCHELL RD SE
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-4413
Mailing Address - Country:US
Mailing Address - Phone:360-865-2022
Mailing Address - Fax:
Practice Address - Street 1:6060 PORTAL WAY
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:WA
Practice Address - Zip Code:98248-7833
Practice Address - Country:US
Practice Address - Phone:360-676-6177
Practice Address - Fax:360-671-3574
Is Sole Proprietor?:No
Enumeration Date:2022-10-27
Last Update Date:2025-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC70018676101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health